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From county courthouses to state legislatures to the halls of Congress, elected leaders are debating the challenging issue of Medicaid.

In Texas, the debate is particularly loud. Could be because there are so many people picking different sides.

On one side are proponents of the federal Affordable Care Act, which would add more than a million adult Texans living near or below the poverty line to Medicaid coverage currently provided for very young children and very poor adults who are elderly, have disabilities or are pregnant.

On another side are expansion opponents who find it fiscally irresponsible to add more people or money into what they see as a broken, unsustainable system.

But there are other voices among the din, voices like that of state Sen. Tommy Williams of The Woodlands, talking about a third option that many in the health-care industry see as the way forward in Texas.

Before the Lone Star State expands eligibility under the ACA or completely closes the door to what the law envisions, Williams recommends adopting a flexible solution to Medicaid reform that isn't an all-or-nothing approach.

Williams' suggestion of expanding Medicaid “managed care” programs to improve and streamline services and reduce costs is exactly what local health providers are doing through a different provision of the Medicaid law called the 1115 Waiver.

Public and private hospitals are partnering with MHMRs, public health departments, academic institutions and county commissioners' courts to create innovative projects that will lead to better outcomes at a lower cost.

We take great pride as Texans in balancing budgets and making smart spending decisions. That fiscally conservative approach abounds at the state capital and at the local level, where health-care decisions should be made. After all, the front doors of our hospitals, community clinics and physicians' offices are where the debate about health care goes from philosophical rhetoric to reality.

We know our community needs and can balance them with the expectations of the taxpaying public. The 1115 Waiver offers the means by which taxpayers can track where their dollars are going and what they are getting for their investment.

Under the Delivery System Reform Incentive Program (DSRIP), Texas Medicaid reform is happening at the local level to train patients to get routine care at community clinics instead of overpopulated emergency rooms that are more costly.

This new system of funding pays based on outcomes rather than on the traditional fee-for-service. Instead of paying for a doctor to see a patient, possibly over and over for the same condition, this new way of providing care is about reducing readmission rates and managing chronic diseases outside of the hospital setting.

Public hospital districts such as JPS Health Network in Tarrant County are footing the bill for designing new ways to provide better care at less cost. And we are willing to put our funds at risk because Medicaid reforms will benefit all Texans by increasing transparency, improving accountability and promoting efficient delivery of care.

Local control of the dollars makes that possible. Some state lawmakers and private hospitals, however, want to siphon off tax dollars from the seven large Texas counties to distribute to the other 247. This distorts Medicaid reform.

Local health-care officials want the state of Texas to maintain the course of reform and not backslide on local control. To maximize the benefits of Medicaid reform, local hospital districts are allocating their tax funds to achieve the kind of change recommended by Williams.

Mandating those funds to the broken, unreformed system of Medicaid is not the voice lawmakers should listen to.